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Hypertensive Emergencies:Diagnosis and Treatment
Jamie Johnston, MD
University of Pittsburgh
School of Medicine
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Today’s Road Map
• Case Presentations
• Definitions
• Evaluation
• Management
• Will not cover pre-eclampsia or pediatric hypertensive emergencies
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Case 1
• 51 year old man admitted to an outside hospital
• CC: Sudden onset of left-sided weakness, severe headache, slurred speech and left facial droop– BP 260/172– Head CT Scan showed Right basal ganglia
hemorrhage with shift
• HPI: Transported by air ambulance to PUH.– Intubated en route due to declining mental status
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Case 1
• PMH - Hypertension - according to wife, patient was non-adherent with prescribed medications– Out patient medications and allergies - not
available– Family History +for HTN/CVA
• Exam PUH - BP 196/130– Positive for Left dense hemiparesis
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Case 1
• Hospital day 2– Dilated right pupil– Emergent right frontotemporal craniotomy
and evacuation of clot
• Subsequent Hospital Course– Difficult to control BP– Pneumonia
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Case 1
• Renal MRI– Right kidney 8.1 cm with three renal
arteries– Left kidney 12.2 cm with two renal arteries
• Patient transferred to rehab at South Side Hospital on 7/19/07
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Question 1
• What is the primary reason for hypertensive emergencies in the USA today?
1. Renovascular Disease2. Pheochromocytoma3. Non-adherence to anti-hypertensive
medication4. Hyperaldosteronism5. Erythropoeitin
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What is the primary reason for hypertensive emergencies in the
USA today?
Ren
ovas
cula
r Dis
ease
Pheo
chro
mocy
tom
a
Non-a
dher
ence
to a
nt...
Hyp
eral
doster
onism
Ery
thro
poeitin
0% 0% 0%0%0%
1. Renovascular Disease
2. Pheochromocytoma
3. Non-adherence to anti-hypertensive medication
4. Hyperaldosteronism
5. Erythropoeitin
10
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When you hear hoof beats…
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Hypertensive Emergency
• According to the Joint National Committee on Hypertension Report
• Severely elevated blood pressure with signs and symptoms of acute end organ damage
• Requires hospitalization
• Requires parenteral medication
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Hypertensive Urgency
• Severely elevated blood pressure without signs and symptoms of acute end organ damage
• Can be managed as an outpatient
• Can be managed with oral medications
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Hypertensive Emergency
• Damage Heart - CHF, MI, angina
Kidneys - acute kidney injury, microscopic hematuria
CNS - encephalopathy, intracranial hemorrhage, Grade 3-4 retinopathy
Vasculature
Vasculature - aortic dissection, eclampsia
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Epidemiology
• Hypertensive emergencies are common– Occur in 1-2% of the hypertensive population– But, 50 million hypertensive Americans– 500,000 hypertensive emergencies/year
• Parallels the distribution of primary hypertension
• Higher in the elderly and African Americans• Incidence in men 2 times higher than in
women
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Epidemiology
• Common associations– Previous history of hypertension– Lack of a primary care physician– Non adherence to antihypertensive
regimen– Elicit drug use (cocaine)
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PathophysiologySudden increase in Systemic Vascular Resistance
BP
Mechanical Stress with endothelial injury, increased permeability, Coag/Plt activation, fibrin deposition
1) Fibrinoid necrosis
2) Ischemia
3) Activation of RAA
4) Proinflammatory cytokines
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Vaughan and Delanty Lancet 2000; 356:411
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Underlying Etiology?
• Unclear, but some candidates
– ACE DD genotype
– Absence of the and subunit of ENaC
– Elevated adrenomedullin levels*
– Elevated natriuretic peptide level*
– Abnormalities in oxidative stress markers and endothelial dysfunction*
– *Correct after effective BP treatment
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Question 2
• What is the most common complaint in hypertensive emergency?
1. Neurologic defect
2. Gross Hematuria
3. Chest pain
4. Headache
5. Epistaxis
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What is the most common complaint in hypertensive emergency?
Neu
rolo
gic d
efec
t
Gro
ss H
emat
uria
Ches
t pai
n
Hea
dache
Epis
taxi
s
0% 0% 0%0%0%
1. Neurologic defect
2. Gross Hematuria
3. Chest pain
4. Headache
5. Epistaxis
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Clinical Presentation
• Variable• Zampaglione et al (Hypertension 27:144, 1996)
– 14, 209 ER visits in one year period– 108 met definition of hypertensive
emergency (0.8%)– Mean Systolic BP 210 + 32– Mean Diastolic BP 130 + 15
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Clinical Presentation
• Frequency of signs and symptoms– Chest Pain 27%– Dyspnea 22%– Neuro defect 21%– Interestingly….
• Headache was only 3% and epistaxis was 0% in this study
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Question 3
• Hypertensive emergency is associated with a threshold BP of
1. Systolic > 225 mm Hg
2. Diastolic > 110 mm Hg
3. Systolic > 250 mm Hg
4. Diastolic > 120 mm Hg
5. All of the above
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Hypertensive emergency is associated with a threshold BP of
Sys
tolic
> 2
25 m
m H
g
Dia
stol
ic >
110
mm
Hg
Sys
tolic
> 2
50 m
m H
g
Dia
stol
ic >
120
mm
Hg
All
of the
above
0% 0% 0%0%0%
1. Systolic > 225 mm Hg
2. Diastolic > 110 mm Hg
3. Systolic > 250 mm Hg
4. Diastolic > 120 mm Hg
5. All of the above
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Threshold BP
• There is no specific BP where hypertensive emergencies occur
• But, organ dysfunction is rare with diastolic BPs < 130 mm Hg– Rate of increase may be more important– Hence, encephalopathy will occur at lower
BPs in pregnancy and in children
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Initial Evaluation
• Focused history– History of hypertension?– How well is hypertension controlled?– What antihypertensives?– Adherence to antihypertensive regimen?– Last dose of antihypertensive?
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Initial Evaluation
• Social History– Recreational Drugs
• Amphetamines• Cocaine• Phencyclidine
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Initial Evaluation
• Confirm BP in both arms
• Use appropriate sized BP cuff
• Cuff that is too small– BP cuffs that are too small falsely elevate
BP measurements in obese patients
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Initial Evaluation
• Assess for end-organ damage
• Vascular Disease– Assess pulses in all extremities– Auscultate over renal arteries for bruits
• Cardiopulmonary– Listen for rales (CHF)– Murmurs or gallops
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Initial Evaluation
• Neurologic Exam– Hypertensive Encephalopathy - mental
status changes, nausea, vomiting, seizures– Lateralizing signs uncommon and suggest
cerebrovascular accident
• Retinal Exam– Lost art– Keith-Wagener-Barker Classification
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Keith-Wagener-Barker Classification
• Grade 1– Mild narrowing of the arterioles– “Copper Wire”
• Grade 2– Moderate narrowing -
Copper wire and AV nicking
• Changes associated with long standing essential hypertension
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Normal
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Grade 1
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Keith-Wagener-Barker Classification
• Grade 3– Severe Narrowing -
Silver wire changes, hemorrhage, cotton wool spots, hard exudates
• Grade 4– Grade 3 + Papilledema
• Grade 3 and 4 highly correlated with progression to end organ damage and decreased survival
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Grade 3 KWB Retinopathy
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Lab Testing
• ECG– LVH, look for signs of ischemia, injury, infarct
• Renal Function Tests (urine included)– Elevated BUN, Creatinine, proteinuria, hematuria
• CBC• CXR - pulmonary edema, aortic arch, cardiac
enlargement
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Lab Testing
• Aortic Dissection?– Suspect with severe tearing chest pain,
unequal pulses, widened mediastinum– Contrast Chest CT Scan or MRI
• Pulmonary Edema/CHF– Transthoracic Echocardiogram – Differentiate between systolic dysfunction,
diastolic dysfunction, mitral regurgitation
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Management
• Elevated BP without target organ damage
• Hypertensive urgency
• Oral meds
• Goal - gradual reduction of BP over 24 - 48 hours
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Management
• Elevated BP with target organ damage
• Hypertensive emergency
• Parenteral meds
• Goal - Reduce diastolic BP by 10-15% or to 110 mm Hg over a period of 30 - 60 minutes
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How Quickly?
• Cerebral Blood Flow Autoregulation– Cerebral Blood constant in normotensive
individuals over range of MAPs of 60 -120 mm Hg.
– In chronically hypertensive patients autoregulatory range is higher
– MAP Range 100-120 to 150-160 mm Hg
• Autoregulation also impaired in the elderly and those with cerebrovascular disease
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How Quickly?
• General rule is to lower MAP by 20% in first hour
• Should always be done with close clinical observation
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Management
• Where?– ICU with close monitoring– Severe requires intra-arterial BP
monitoring
• Which Parenteral meds?
• Depends on the situation
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Question 4
• Which of the following drugs should not be used to treat hypertensive emergency?
1. Sublingual Nifedipine2. Labetolol3. ACE Inhibitors4. Nicardipine5. 1 and 3
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Which of the following drugs should not be used to treat hypertensive
emergency?
Sublin
gual N
ifedi
pine
Lab
etolo
l
ACE In
hibito
rs
Nic
ardip
ine
1 a
nd 3
0% 0% 0%0%0%
1. Sublingual Nifedipine
2. Labetolol
3. ACE Inhibitors
4. Nicardipine
5. 1 and 3
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Preferred Agents
• Beta blockers– Labetolol– Esmolol
• Calcium Entry blocker– Nicardipine
• Dopamine-1 receptor agonist– Fenoldapam
• Vasodilators - nitroprusside/nitroglucerin
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Scenarios
• Our Case - Acute ischemic stroke/cerebrovascular bleed
• Agents– Fenoldopam– Labetolol– Nicardipine
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CVA or Ischemic Stroke
• BP elevation after CVA or ischemic stroke can be protective to preserve cerebral perfusion
• Hold on aggressive lowering unless– Thrombolytic therapy anticipated or– BP excessively high ( SBP > 220 mm Hg or DBP
>120)
• BP Goal for thrombolytic therapy is to lower SBP if > 185 or DBP >110
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Cardiac Conditions
• Acute Pulmonary Edema with systolic dysfunction– Nicardipine– Fenoldopam– Sodium nitroprusside– Nitroglycerin– Loop diuretic
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Cardiac Conditions
• Acute Pulmonary Edema with diastolic dysfunction– Esmolol, metoprolol, labetolol– verapamil– Nitroglycerin– Loop diuretic
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Cardiac Conditions
• Acute myocardial ischemia– Esmolol, labetolol– Nitroglycerin
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Sympathetic Crisis
• Generally in association with recreational drugs such as cocaine, amphetamine or phencyclidine
• Sudden cessation of clonidine or Beta-adrenergic antagonist
• Pheochromocytoma - rare
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Question 5
• Which of the following drugs should be avoided in sympathetic crises with hypertensive emergency?
1. Phentolamine2. Benzodiazepine3. Labetolol4. Nicardipine5. Fenoldopam
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Which of the following drugs should be avoided in sympathetic crises with
hypertensive emergency?
Phen
tola
min
e
Ben
zodia
zepin
e
Lab
etolo
l
Nic
ardip
ine
Fen
oldopa
m
0% 0% 0%0%0%
1. Phentolamine
2. Benzodiazepine
3. Labetolol
4. Nicardipine
5. Fenoldopam
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Sympathetic Crisis
• Beta-adrenergic antagonists will result in unopposed alpha-adrenergic stimulation
• In cocaine use, Beta blockers can– Increase blood pressure– Worsen coronary artery vasoconstriction– Decrease survival
• Avoid beta blockade (including non selective agents such as labetolol)
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Sympathetic Crisis
• Recommended Drugs– Nicardipine– Fenoldopam– Verapamil– Benzodiazepine– If pheo suspected use phentolamine
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Aortic Dissection
• Treatment is paramount– 75% of patients with ascending aortic
dissection die in 2 weeks of the acute episode without successful therapy
– 5 year survival is 75% with successful intervention
• Khan et al. Chest 2002, 122:311• Kouchoukos New Engl J Med 1997; 336:1876
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Aortic Dissection
• Vasodilator alone?– Causes reflex tachycardia– Increases cardiac ejection velocity– Increases aortic shear forces– Extends the dissection
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Aortic Dissection
• Standard therapy– Beta-adrenergic blocker plus vasodilator– Esmolol + Nicardipine or fenoldopam
• Nitroprusside can be used as well
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Acute Post Operative Hypertension
• Frequent in post-operative state (20-75%)
• Hyper-responsiveness to surgical trauma– Increased stress hormones?– Activation of RAA?
• Also hypothermia, hypoxia, carbon dioxide retention, bladder distention
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Acute Post Operative Hypertension
• Prevention– Safe to give antihypertensives pre-op– Hold diuretics
• Treatment - BP thresholds vary– Control pain and anxiety– While NPO use nicardipine, esmolol or
labetolol– Resume oral medications when possible
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What happened to sodium nitroprusside?
• Mansoor and Friedman. Heart Disease 2002; 4:358– Sodium nitroprusside recommended for all
hypertensive emergencies except eclampsia
• Marik and Varon. Chest 2007; 131:1949– Sodium nitroprusside recommended for
• acute aortic dissection • acute pulmonary edema with systolic
dysfunction
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“riding the pride”
• Disadvantages of sodium nitroprusside– Decrease cerebral blood flow and increases
intracranial pressure– Can reduce regional blood flow in coronary artery
disease– Risk of cyanide toxicity
• Use when other agents not effective– Monitor thiocyanate levels– Avoid in renal or hepatic dysfunction
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Have we made progress?
• First described by Volhard and Fahr– Die Brightsche Nierenkrankenheit: Klinik
Patholgie und Atlas. Berlin, Germany, Springer 1914:247
• Keith, Wagener, Barker Am J Med Sci, 1939;197:332– Mean survival of patients with htn and
grade 4 retinopathy was 10.5 mo with none living beyond 5 years
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We have made progress
• Development of antihypertensive drugs
• Increased diagnosis of hypertension
• Increased ICU settings
• Survival of patients with hypertensive urgency and emergency is 18 years compared to 21 years in those with uncomplicated hypertension
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Thank you!
Questions?
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Messerli N Engl J Med 1995;3321038.
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Messerli N Engl J Med 1995;3321038.